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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE <br /> ;I CE 'USEc1601 E. Hazelton Ave. , Stockton, Calif, ' <br /> Telephone : (204) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District: . <br /> JOB ADDRESS/LOCATION 6,p ' CENSUS TRACT r <br /> Owner's Name <br /> -.s Phone - <br /> Address.� <br /> 3 <br /> City <br /> Contractor's Name License # Pid�FoneG� <br /> TYPE OF- WORK (Check) ; NEW WELL '/ / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION A,& <br /> PUMP REPAIR /ter./ PUMP REPLACEMENT /_7 I; <br /> Other / / — a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER ' <br /> PROPERTY LINE = PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL (� j <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. -of Well Excavation1 <br /> Domestic/private Drilled - Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing <br /> ` Irrigation `Gravel' Pack Depth of-Grout Seal - <br /> y 4 <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal. Other Other Information <br /> GeophysicalSurface Seal Installed By: t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �.e r H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> —3. <br /> PUMP Awqm: ,State Work Done -� <br /> PES•TRUCTION OF:WELL: 'W.e11 ,Diametex Approximate Depth <br /> De�s°crii a Material and Procedure,"- <br /> ' <br /> y <br /> I hereby agree to "comply with all-laws and regulations .of the San Joaquin Local Health District <br /> and the State of California pertaining.-.to or regulating well-construction. Within FIFTEEN DAYS <br />'after completion of .my work ori a new c�e11 I will furnish the.San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the`•, ell .and_th�o 'ify them before putting the well in use. The :above <br />-information-, is true to the best.. kn wle,d.g and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR, TO GRUTING . AND A FINAL CT 0 <br /> SIGNET} TITLE <br /> ( W PLOT PLAN ON VERSE .SIDE) <br /> r" FOR DEPARTMENT :USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY ' DATE <br /> ADDITIONAL COMMENTS:. <br /> PHASE II GRQ11TINSPECTION PHASE {III FINAL INSPECT ON ' <br /> INSPECTION BY DATEINSPECTION BYjt DATE AR 1.7,1f <br /> E H 1.426 Rev. 1-74 1 f Z , 2M 1 <br />